To DKA or not to DKA, that is the question...

I'm a new ICU nurse, I've been on this unit for about 4 months. Last night I received an admission which kinda confused me.

Here's the info: (adjusted to protect his privacy)

28 y/o male, type 1 diabetic diagnosed as a child. N/V for about a week. When he arrived in the ER his blood sugar was 170-ish. Na 142, CO2 <10, Chloride 111, H+H wnl, but on the high end, Anion gap 21, elevated WBC, pH on ABG was 7.0, acetone level was high.

Diagnosis was dehydration from the n/v and he was given 4L NS over about 3-4 hours. Checked another accucheck and his sugar was 350's. Orders were received for admission to the ICU and DKA protocol. He was started on an insulin gtt @ 9 units per hour, based on the weight based calculation built in to the protocol. 2 hours later, still in the ER, his sugar was 64. Anion gap was still 20. ER nurse turned off the insulin gtt and called the doc who didn't give any additional orders. She called me report and I paged the doc who told me to check an accucheck once he gets to the ICU and call him with the results. Upon admission to my unit, his sugar was 120. I received orders for D5 1/2NS @ 200, 1 amp D50, restart the insulin gtt @ 1 unit/ hr, check an accucheck in 1 hour, call with results. Needless to say, 1 hour later his blood sugar was nearly 400. The doc proceeded to ignore the titration formula on the protocol for the next 5 hours (during which time I charted my ass off, cya) until his accuchecks were back down to about 175. (once his sugars were down I managed to convince the doc to use the protocol for future titration) By the time I left his gap had decreased to 17 and pH on VBG was 7.24, acetone level was still positive.

My question is this: should we have been using the DKA protocol to correct this acidosis or is there another way to fix this? Obviously it was working, but it seemed as though we were putting him into DKA in order to correct the A portion of DKA...

Sounds like starvation ketoacidosis. Poor intake for > 3 days, high gap, positive ketones, but normal blood glucose. I've personally never seen a DKA patient come in with an initial normal glucose. I have however seen starvation ketoacidosis where blood sugars were almost a non-issue and you were just cranking in fluids, D5 or D5/.45 later on for a glucose source and intracellular hydration.

You really didn't need the DKA protocol. You're going to give fluids and the pH would normalize itself over time, you didn't need to be mixing bicarb into the fluids or anything insane like that.

Sounds like starvation ketoacidosis. Poor intake for > 3 days, high gap, positive ketones, but normal blood glucose. I've personally never seen a DKA patient come in with an initial normal glucose. I have however seen starvation ketoacidosis where blood sugars were almost a non-issue and you were just cranking in fluids, D5 or D5/.45 later on for a glucose source and intracellular hydration.

You really didn't need the DKA protocol. You're going to give fluids and the pH would normalize itself over time, you didn't need to be mixing bicarb into the fluids or anything insane like that.

Agreed...had one like this last week- MD refused to D/C insulin gtt, pt had FSBS on 40....pushing d50 all day until doc finally decides.."oh, well maybe thats a little low"....UGH

Gave him D5 1/2 NS and started him eating/drinking with zofran q6...fixed....

We would definitely still keep that patient on the DKA protocol, since they are still in ketoacidosis regardless of the BG. I think Nurses are often under the false assumption that the goat of DKA treatment is to normalize the BG, which is really sort of irrelevant. What the patient needs is insulin, if that means giving d5, d10, or d50 then so be it, but to clear the ketones, stop ketone production, normalize the gap and ph the patient needs insulin, not a just a normal BG.

Our protocol is to add D5 to the IVF when the BG is less than 250 if the gap has not closed, and to switch to d10 if the BG falls below 150 prior to the anion gap closing.

We would definitely still keep that patient on the DKA protocol, since they are still in ketoacidosis regardless of the BG. I think Nurses are often under the false assumption that the goat of DKA treatment is to normalize the BG, which is really sort of irrelevant. What the patient needs is insulin, if that means giving d5, d10, or d50 then so be it, but to clear the ketones, stop ketone production, normalize the gap and ph the patient needs insulin, not a just a normal BG.

Our protocol is to add D5 to the IVF when the BG is less than 250 if the gap has not closed, and to switch to d10 if the BG falls below 150 prior to the anion gap closing.

I don't think you understand the difference between diabetic and starvation ketoacidosis. Diabetics get the ketoacidosis from lack of insulin to shuttle the blood glucose into cells. Starvation ketoacidosis patients get the ketoacidosis because glycogen stores are exhausted so they convert to ketones for an energy source.

Giving insulin to a starvation ketoacidosis patient is only going to move the blood glucose into cells when they don't have much to move. Say their glucose is 110 and you give 5 units/hr of insulin, in an hour your recheck may be 60. Are you going to keep running insulin? No. You're going to be doing like LaurelRN said and pushing D50 throughout your entire shift.

Insulin is not the problem in starvation ketoacidosis, it's the glucose availability. Replace the sugar, and the problem will fix itself.

I agree, diabetic acidosis comes on more suddenly and with a much higher blood sugar. Without immediate treatment of DKA, the outcome will not be good. As others said, there are other types of acidosis.

In addition to being a nurse, I am also a type 1 diabetic. I went into DKA once due to insulin pump failure. Mine was a classic case of diabetic ketoacidosis- admitting blood sugar of 570, "large" ketones, dehydration and hyperkalemia and extremely low potassium..

I had a pt this week, 21yo female, insulin dependent diabetic, who was DKA with normal blood glucose -- 150s to 170s on admit. She was positive for flu A. She was originally admitted for dehydration until they pulled a gas (acidotic) and saw that her gap was 24.

When she came to the unit I treated her like I would treat anyone on the DKA protocol who had a BG under 250 -- started her on D5 1/2NS along with the insulin drip, at 7.5 units/hr per her weight. She was confused and asked me why she was in DKA if her blood sugar was normal. I explained as best I could that the glucose was just a part of the problem, her real problem was an acid-base imbalance in her blood related to positive and negative ions, and by giving her dextrose and insulin at the same time, we were facilitating a fluid and ion shift that would start to normalize her condition. (Way oversimplified and slightly inaccurate, but I didn't have all day.) Her sugars stayed in normal range, but we know our MDs won't even consider stopping an insulin drip until the gap is closed -- at least 14, sometimes 12 depending on the doc. If they are low we push D50 and/or switch to D10 depending on the protocol. She didn't drop for me though, in the 4 hours I had her.